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SAN JOAQUIN ~LOCAL HEALTH-DISTRICT <br /> -TOT"OFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> 77- Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z71ldYa' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made tol the San Joaquin Local Health District for a permit to construct.„ <br /> and/or install the work herein described. This application is made in compliance with San Joaquin ' <br /> County Ordinance No. .1862 and the Rules and Re ulations of the Sall Joaquin Local Health,Districr`. <br /> JOB ADDRESS/LOCATION �P <br /> d' CENSUS TRACT <br /> Owner's Name Phone <br /> Address a© Cityx <br /> ' `, ,Z. License �G � Phone <br /> Contractor s Name <br /> aczi <br /> a. <br /> TYPE OF WORK (Cheek): NEW WELL L� DEEPEN /� RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR J PUMP REPLACEMENT IT <br /> Other '1 / <br /> DISTANCE TO-NEAREST: SEPTIC .TANK,, SEWER LINES PIT PRIVY <br /> � -� c:.?N*SEVAGE-DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> °P.ROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC rrm R <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSf. ,.:.: F . <br /> Industrial Cable Tool Dia. of Well-Excavation <br /> Domestic/Private Drilled- Dia. of Well Casing <br /> Domestic/public Driven ' Gauge of Casing <br /> Irrigation Grave'I Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> .Disposal A Other _ Other Information <br /> Geophysical Surface Seal Installed-BY: <br /> PUMP INSTALLATION: <br /> ContractorC.� a i" <br /> Type of"Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 'PUMP .REPAIR: / / State Work Done <br /> Approximate Depth ' <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material` and Procedure - <br /> r <br /> I .hereby agree �to comply with all laws. and regulations of the San Joaquin Local Health D16tr*-Ct <br /> and the State- of California pertaining to or regulating well•construction. Within FIFTEEN DATIS <br /> after completion of my work on anew well. I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the-well in use. The ab�ove' . <br /> information is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT ISPECTI , <br /> PRIOR TOG UTING AN A IAL INSPECTION. <br /> SIGNED TITLE f. <br /> D y� LAN 'ON EVE= SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> } APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G jiNSPECTION PHA SII FINAL I PECTION <br /> INSPECTION BY DATE INSPECTION BY DA <br /> �+7b 2tt- <br /> E H 1426 Rev. 1-74 C_a - <br />